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Transcript of PSF FINAL SHOWCASE EVENT 29 TH SEPTEMBER 2015 .
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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WELCOME
DR EMMA VAUX CEO & EXECUTIVE CHAIR
PATIENT SAFETY FEDERATION
http://www.patientsafetyfederation.nhs.uk
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Patient Safety
Tim BensonPatient Leader, RBH
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What patients want
• To feel better and do more• Excellent service
– Safe and reliable– Right every time– Not worried
• To feel as much as possible in control
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Quality Culture
• Institute of Medicine– To err is human (2000)– Crossing the quality chasm (2001)
• NHS Quality Framework– Outcomes– Experience and Safety
• Listen to the patient– Most important stakeholder– Self-efficacy– Patient perceptions
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Safety is not...
• Counting errors– Complaints handling– Never events– Coroner's inquests
• Inspections– CQC– Litigation – Blame culture
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Deming’s 14 points
1. Constant improvement2. New philosophy (TQM)3. Cease dependence on inspection4. Stop procuring on basis of price alone5. Design in quality6. Training on the job7. Leadership is to help people do better8. Drive out fear9. Team work not demarcation10. Eliminate targets11. Pride in work for staff12. Pride in work for managers13. Vigorous education and improvement14. It is everyone’s job
– W.Edwards Deming. Out of the Crisis. MIT Press 1982
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Question
• Do we need a safety measure based on patients’ perceptions?
• If so what aspects are relevant?
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Zero tolerance to never events: standardise, educate and harmonise.
Tom Crawford Project Lead
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Never events• Are a particular type of serious incident
that meet all the following criteria • They are wholly preventable, where
guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers
Ref: NHS England Patient Safety Domain
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BackgroundDate of incident Location of incident Category Description of the incident
09-Sep-13 Theatres Surgical error Retained Guide wire
23-Sep-13 Theatres Surgical error Retained humeral protector plate
28-Jan-14 Theatres Surgical errorWrong acetabular liner (size) inserted during total hip replacement.
31-Jan-14PCEU
OphthamologySurgical error Wrong size intraocular lens
21-Mar-14Theatres
AnaestheticsSurgical error Retained guide wire
25-May-14
Theatres Surgical error Wrong site surgery
25-Jun-14 Theatres Surgical error Wrong tooth extraction
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1. Zero tolerance to never events2. To improve attitudes limiting
safety behaviour and practice3. Culture of reporting of adverse
events 4. Reduce waste (cost of
complications, cost to patients, cost to staff)
Aim/Purpose
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Domain 1. Safety Culture
Aim:Improving safety
culture can improve staff
behaviour and patient safety
outcomes
Aim:A good safety
culture, requires
leadership and frontline staff taking
shared responsibility
Aim:Providing learning &
information that can
contribute to an
understanding of Human Error and
prevention .
Aim: Implementation
of good practice helps to ensure safe standards of patient care
are delivered
Aim:Reporting and
learning the lessons from incidents to
ensure it will not happen
again
Aim:Patient
engagement can deliver
more appropriate
care and improved outcomes
Domain 2 Leadership
Domain 3 Promote Reporting
Domain 4.Promote Learning
Domain 5Implementing Best practice
Domain 6. Patient & staff Involvement
Safe Strategy
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Developments and Successes 1. Published Patient Safety Newsletter detailing recent serious
incidents and lessons learned, disseminated to all staff by email and hard copies in the staff rooms.
2. Baseline assessment of theatre safety culture using the University of Texas Safety Attitudes Questionnaire .
3. Developed standing safety agenda with performance reporting against key metrics .
4. Implement the WHO patient safety curriculum and incident report scenario pilot to improve junior doctor’s awareness .
5. Developed an audit tool to assess adequacy and method of completion of WHO Surgical Safety Checklist
6. Human factors training for theatre staff7. Implemented formal briefing/debriefing tool.8. Bespoke leadership training programme for Consultant Surgeons
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2.5
7.5
12.5
17.5
22.5
27.5
32.5
Days between Never Event(s) Jun 2014_Sept 2015
159 days 293 days
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Domain 2 Leadership
Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014/15 Q1 2015
Rate/100 proc
1.33101851851852
1.75032547374512
1.39888632350944
1.53021187549045
1.75755584756899
1.8 2.45749202975558
2.06130370766966
1.99870214146658
1.1
1.3
1.5
1.7
1.9
2.1
2.3
2.5
RBFT Theatre Datix Rate/100 Procedures April 2013_June 2015
Target 2.0
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Challenges and Lessons learnt
1. Team work2. Observational audit3. Achievable targets4. Pace of behavioural change5. Operational pressures for optimum theatre utilisation6. Geographical spread of operating theatres7. Clinical engagement
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Making medicines safer for patients(The Safe Medicines Pathway
Toolkit)
Patient Safety Federation Conference Sept 15
Jane Hough, Associate Director, NHS Specialist Pharmacy Service
Triss Clark, PSF Programme Director & PSF Project Manager for SMP
Safe Medicines Pathway
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Content of the presentation
• Background • Aim/Purpose• Developments and Successes• Challenges & Lessons Learnt
Safe Medicines Pathway
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Background to project starting • No Needless Medication Error work-stream• PSF held meetings with stakeholders • Concern raised about large number of
medication errors • Safe Medicines Pathway conceived
Safe Medicines Pathway
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Aims 1. To simplify, standardise and make reliable
some of the elements of the medicines pathway: such that the likelihood of errors occurring is reduced.
2. To share work through a Web-based tool kit.
Safe Medicines Pathway
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Purpose of the Project• To understand the processes undertaken when
information about patient’s medicines and the medicines themselves enter and leave the system.
• To test changes to the system in one organisation
• To work with other organisations in the PSF geography to test tools developed
• To share the experiences, learning and tools through a web-based tool-kit
Safe Medicines Pathway
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Who is responsible for writing up the Drugs
Clarity of Drugs
Charts
Timing of LTC Meds being written up
Portering Collection
and Distribution
Portering Collection
and Distribution
Use or Not of PODs
Lockers
Use or Not of PODs
Lockers
• Themes
LTC Medicati
on Omitted
Medication Omitted at Initial
Visit
Loss of Medication
Delays in the writing
of TTO’s
Single Storage space for all
Medication on
the Wards
Safe Medicines Pathway
Duplication of Medication
Duplication of Medication
Lack of Consistency in the use of technology i.e. iPADS
New meds only given in certain departments
Delay in Writing TTO’s Condition
of Patient on admission Communication
with GP’s/Community
Pharmacists
Communication with
GP’s/Community Pharmacists
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Story Board
No one had told her, she had started on new Medication
No one had told her, she had started on new Medication
Patient/family sometimes return to collect meds
Patient/family sometimes return to collect meds
??
Some patients unaware of the medication they are taking
Some patients unaware of the medication they are taking
Looked after his own meds at home. Did not need additional medication – had more supplies at home
Looked after his own meds at home. Did not need additional medication – had more supplies at home
Patients eye drops not charted throughout stay. Lost somewhere along the pathway
Patients eye drops not charted throughout stay. Lost somewhere along the pathway
She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge
She was pleased with the medicine process – agreed it would be helpful to see the Community Pharmacist on discharge
Pt sent home without own meds; meds thrown out by Nursing Staff
Pt sent home without own meds; meds thrown out by Nursing Staff
Safe Medicines Pathway
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Developments and Successes • Data collection tools • Interventions across prescribers, nursing
and pharmacy• Patient involvement • Working with an FY2• Improvement in medicines reconciliation • DART campaign (prescribing)• SMP Website
Safe Medicines Pathway
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Interventions
Summary Safe Medicines Pathway proposed projects
Patient history
taken, including
medication
Diagnosis made
and medicines
prescribed
Medicines
sourced
Medicines given Discharge Admission
Pharm
Nurse
Dr Nurse Dr
Dr Pharm Nurse Nurse Pharm
Nurse
Dr
Projects:
Prescribing of high and low risk medicines when a patient
is admitted to hospital and appropriate documentation.
Prescribing Accuracy Audit (legality and legibility).
Audit based on the EQUIP study looking at prescribing
accuracy and high risk medicine prescribing.
Allocation of function tool – medicines reconciliation
Review of pharmacist medicines reconciliation
Projects:
Observational audit on delayed and omitted doses.
Critical decision making tool
Projects:
Information forms part
of project 1. Other
aspects – discharge
group.
Aim: Improve safety of prescribing for patients and reduce risk of harm caused by medication errors relating to medicines reconciliation – Better communication between healthcare professionals and others involved in the transfer of patient care.
Aim: Reduction in number and severity of prescribing errors in particular in relation to high risk medicines (higher potential for serious patient harm).
Aim: Reduction of delays in medication being available on the ward for timely administration to the patient.
Aim: Improve patient safety through timely administration of the correct medicine, particularly in relation to medicines which are considered “time critical”
Aim: Reduce errors relating to patient discharge (including unintentional changes) from the inpatient care setting and prevention of patient harm in relation through accurate communication at discharge.
Project 1:
Medicines
Reconciliation
Project 2:
Prescribing
accuracy
Project 3:
Medicines
provision to the
ward
Project 4:
Timely
administering of
medicines
Project 5:
Improving
communication to
GP at Discharge
Safe Medicines Pathway
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Challenges and Lessons learnt • Team/Timescales • Releasing staff and running a project on
top of “day job”• Complexity of the pathways • Engagement and clarity of purpose • Impact of the introduction of EPR
Safe Medicines Pathway
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Purposeful Observation
• People do not always do what they say they do
• People do not always do what they think they do
• People do not always do what you think they do
• People cannot always tell you what they need
• Things are not always as they seem …….
(adapted from IDEO)
Safe Medicines Pathway
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Thank you!Contact Details
PSF Project Manager for SMP – Triss [email protected] Tel 01865 221557
Project Lead - Jane [email protected]
Safety/Improvement Expert – Dr Clare Crowley [email protected] Tel 01865 857879
Safe Medicines Pathway
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Improving Safety & Quality of Antimicrobial Prescribing in
Berkshire HFT
Kiran Hewitt, Lead Clinical Pharmacist (Project Lead)
Jenny Perry, Senior Pharmacist (Project Manager)
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Background (1)
UK 5 year antimicrobial resistance strategy 2013-187 key areas for action, including
optimising prescribing practice, improving IC, improving education and training
ESPAUR PMs commission on ABR by the
Wellcome Trust EAAD 18th November
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Background (2)Between 2010 and 2013:
Antibiotic use by 6%general practice prescribing by
4%prescribing to hospital inpatients
by 12%other community prescriptions
(dentists, out of hours prescribers, nurses, NMPs) by 32%
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Audit Standards & Results Criteria Audit Criteria – Standards = 100% Findings
1 Relevant cultures will be taken before antimicrobial therapy is started 49%
2 Drug allergies (antimicrobials) will be noted on the chart 74%
3 Route of administration will be indicated on the chart 98%
4 Dose and frequency will be indicated on the chart 97%
5 The antimicrobial start date will be noted on the chart 85%
6 The duration will be noted on the drug chart 77%
7 Indication will be noted on the chart 47%
8 Treatment will be in line with trust guidelines 83%
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Aims • Leadership role (pharmacist) to drive stewardship across the
Trust• Better access to guidelines – to support remote working • Training and better education of prescribers - main focus of
action plan and internal self assessment • Use of technology to enhance the deliver of these• Networking and regional collaboration with subject experts
– Membership of TVWAPN (sub group of Chief Pharmacists group)• Guidelines review in collaboration with both local hospitals
• PSF bid April 2014
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Developments (1)• Recruitment of Project
Manager Sept-14• Purchase, training and
development of Microguide smartphone app– Sept to Nov-14
• Key Benefits:
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Developments (2)• Initial Promotion
– EAAD launch • Face to face intro for all ward staff
– Presentation of audit findings, App demo, posters, Start Smart Then Focus reminder cards
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Developments (3)• Trust-wide Publicity:
– Annual Quality Improvement Event – first prize winner (Nov-14)
– IC Link Practitioners annual study day (Nov-14)– Trust Best Practice and Innovation Event (Feb-15)
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S1 S2 S3 S4 S5 S6 S7 S80
20
40
60
80
100
120
Nov-13
Feb-15
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Developments (4)• E-learning package introduction • Original plan – regional module to utilise
local and regional expertise = best option• Delayed launch
– Options appraisal for alternatives– Bespoke Trust package developed – Feb-15
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• Essential training requirement agreed– for medical and nursing staff groups, pharmacy– Managed through L&D
• User group feedback prior to launch• Added to medical trainee induction • “Start Smart Then Focus” and App posters on
wards• GP and Out of Hours GP presentation – May-15
Successes (1)
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Targetted training for GPs PDSA 3
e-learning module formally implemented PDSA 5
Targetting S1 on WBCH PDSA 4
Three training sessions for all ward staff on WBCH PDSA 1a)
Training roll out on Rose ward PDSA 1b)
Display StartSmart Poster PDSA 2
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Nationally - • NICE Guidelines NG15 – AMS: systems and
processes for effective antimicrobial medicine use– August 2015
• Baseline audit of compliance = 41%– Establish key areas of improvement
• formal approval of AMS programme• AM team development• AM Pharmacist • Better communication across care settings• Robust documentation of Rx decisions
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Challenges • Trust wide roll out – Oct-15 for all CHS wards, Dec-15 for MH • Audit of other non-inpatient areas?• Improvements over time – sustainability? Champion/lead needed• E-learning for local GPs and sharing with others• CCG engagement for primary care
– Regional group membership already established (TV&WAPN)– – MUS conference
• Work with local acute trusts – Own agenda– Internal influence and Board approval – Expanding boundaries in the East
• Sharing our “package” with the TV&W group – Already the experts!
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Lessons Learnt• What would we have achieved without PSF support?• A lot can be achieved with commitment• Sufficient project management time is essential.• QI experience important.• Does it make a difference to patient care?
– yes • Future area for research• Applicable to all – yes
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Is avoidable mortality a good measure of the quality of
healthcare?
Dr Helen Hogan Clinical Senior Lecturer in Public HealthLondon School of Hygiene and Tropical
Medicine
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Outline
• What drives interest in avoidable mortality
• Problems with use as a measure of hospital quality
• Approaches to measurement and what we have learned
• Local and national developments
• The future
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Why it matters?
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Limitations of avoidable deaths a measure of quality
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Measuring avoidable death using population-level data
• HSMR/ SHMI/ RAMI• Coded adverse events linked to death• Known avoidable harms linked to death• Patient Safety Indicators• Prospective surveillance systems
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Measuring avoidable deaths at patient level
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What have we learnt so far
• Preventable Incidents Survival and Mortality studies (PRISM) 1 and 2
(co-applicants Nick Black, Frances Healy, Graham Neale, Richard Thomson, Charles Vincent, Ara Darzi)
• Association between avoidable deaths (RCRR) and excess deaths (hospital-wide mortality ratios)
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PRISM 1 Study
• 2010/2011• Aims:
– estimate proportion of avoidable hospital deaths– identify ‘problems in care’ and contributory factors – estimate years of life lost
• Method:– RCRR (1000 adult deaths across 10 acute Trusts in
England)– Trained, retired doctors with standard form
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Findings• 75% good or excellent care• 11.3% ‘problem in care’ contributing to
death• 5.2% deaths probably avoidable
– range 3% - 8% (low variation between Trusts)– estimate 11,859 avoidable adult deaths/year in
England NHS
• Life expectancy of avoidable death patients– 60% patients had life expectancy less than 12 months
• Inter-rater reliability Kappa 0.49
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Problems in care identified in cases of preventable deathStage of patient journey
Types of problem identified
Preadmission Poor monitoring of warfarinDelays in admission for hospital procedureContraindicated drug prescribed in outpatients
Early in admission
Failure to diagnoseDelayed diagnosisWrong diagnosisFailure to identify the severity of underlying conditions and risks posed by the chosen therapeutic approach Failure to optimise preoperative state
Care during a procedure
Procedure conducted in inappropriate environmentTechnical error
Post procedure Inadequate monitoring (fluid balance, infection)Poor assessment
Ward care Inadequate monitoring of overall condition, fluid balance, laboratory tests, side effects of medications (especially warfarin), pressure areas and infectionUnsafe mobilisation leading to serious fallsHospital acquired infectionPrescription of contraindicated drugDelay in undertaking required procedure
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PRISM 2 Study• Based on recommendations emerging from the
Keogh review
• Relationship between ‘excess mortality rates’ and actual ‘avoidable deaths’
• Findings to support introduction of a new national outcome framework “hospital deaths attributable to problems in care” and systematic approach to local mortality review
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PRISM 2 Study• 2014/2015• Extend PRISM 1 to further 24 Trusts• Similar method to permit analyses of combined
data from both studies (n=3,400 records)• Random sample of Trusts across 4 strata of HSMR• Trained reviewers (70% current consultants, 30%
retired)• Linear regression to determine the percentage
increase in avoidable death proportion for a 10 point increase in HSMR/SHMI
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Findings• 78% good or excellent care• 9.4% ‘problem in care’ contributing to
death• 3.0% deaths probably avoidable
– range 0% - 9% (low variation between Trusts persists)
• Inter-rater reliability Kappa 0.35
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Combined Findings
• 3.6% probably avoidable• no statistical significant association between
hospital SMRs and the proportion of avoidable deaths
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The future
• Local Mortality Review– Standardised self-assessment will ensure robust process
• National approach to training and materials• Electronic database/ NRLS• All deaths screened, high risk cases selected for in-depth• Multidisciplinary process
• National Tracking of Outcome Indicator• Random sample of NHS deaths • National panel of trained reviewers (multi-disciplinary)• Multiple reviewers per record
• Timetable: Invitation to tender via HQIP– http://hqip.org.uk/tenders/rcrr%20tender%202015/
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The future• Direct comparison of Trusts based on avoidable X
deaths
• Develop notional avoidable death proportions ??• Use a coherent set of indicators known to be
associated with quality e.g. hospital acquired infections and measure as robustly as possible
• Develop indicators that reflect integrated care/ quality of care across health systems
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk
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Passing the Baton
29/09/15
Geoff Cooper – Patient Safety Collaborative Manager
Wessex Patient Safety Collaborative
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Patient Safety Federation
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Wessex and Oxford PSCs
Wessex and Oxford Patient Safety Collaboratives are part of a network of 15 Collaboratives established in 2014 by NHSE to tackle the leading causes of avoidable harm to patients.
The collaboratives aim to empower local patients and healthcare staff to work together to identify safety priorities and develop solutions.
These solutions will then be implemented and tested within local healthcare organisations before being shared nationally with the other collaboratives.
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Patient Safety Federation
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Patient Safety Federation
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Collaboratives and Clusters
Patient Safety Federation Wessex PSC National Cluster
Sepsis (NW Coast)
Global Comparators (Sepsis)
Safe Medicines Pathway * (Meds Opt) (Wessex)
Anti-microbial prescribing * (Meds Opt (Wessex)
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Local Priorities / Breakthrough Series
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Wessex PSC Work Streams /Programme Model
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Passing the Baton (Wessex)Patient Safety Federation
Wessex Patient Safety Collaborative
Safe Medicines Pathway
• Pharmacy and Transfer of care around medicines projects - Wessex AHSN Medicines Optimisation Programme
Anti-microbial prescribing
• Work programme being led by the Thames Valley and Wessex Antimicrobial Pharmacists Network
Sepsis • Dr Matt Inada-Kim (WPSC Faculty) working for PSF and WPSC• This programme will remain within organisations with Wessex PSC facilitation via
the current BTS Collaborative which includes teams from:• Dorset County Hospital NHS Foundation Trust• Dorset Healthcare University NHS Foundation Trust• Hampshire Hospitals NHS FT• NHS Dorset Clinical Commissioning Group• NHS West Hampshire Clinical Commissioning Group• Poole Hospital NHS Foundation Trust• Portsmouth Hospitals NHS Trust• The Royal Bournemouth & Christchurch Hospital NHS FT• Salisbury NHS Foundation Trust• Southern Health NHS Foundation Trust• South Central Ambulance Service NHS Foundation Trust• Wessex Paediatric Critical Care Network• University Hospital Southampton NHS Foundation Trust
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PSF FINAL SHOWCASE EVENT
29TH SEPTEMBER 2015
http://www.patientsafetyfederation.nhs.uk